Category: health

The short story “Anekdote zur Senkung der Arbeitsmoral” (“An anecdote about the lowering of work ethic”) is one of the most famous stories written by the German author Heinrich Böll. In the story, an affluent tourist encounters a poorly clad fisherman who is comfortably napping in his boat. The assiduous tourist accidentally wakes up the fisherman while taking photos of the peaceful scenery – blue sky, green sea, fisherman with an old-fashioned hat – but then goes on to engage the lounging fisherman in a conversation. The friendly chat gradually turns into a sermon in which the tourist lectures the fisherman about how much more work he could be doing, how he could haul in more fish instead of lazing about, use the profits to make strategic investments, perhaps even hire employees and buy bigger boats in a few years. To what end, the fisherman asks. So that you could peacefully doze away at the beach, enjoying the beautiful sun without any worries, responds the enthusiastic tourist.

I remembered Böll’s story which was written in the 1960s – during the post-war economic miracle years (Wirtschaftswunder) when prosperity, efficiency and growth had become the hallmarks of modern Germany – while recently reading the book “Du sollst nicht funktionieren” (“You were not meant to function”) by the German author and philosopher Ariadne von Schirach. In this book, von Schirach criticizes the contemporary obsession with Selbstoptimierung (self-optimization), a term that has been borrowed from network theory and computer science where it describes systems which continuously adapt and “learn” in order to optimize their function. Selbstoptimierung is now used in a much broader sense in German culture and refers to the desire of individuals to continuously “optimize” their bodies and lives with the help of work-out regimens, diets, self-help courses and other processes. Self-optimization is a routine learning process that we all engage in. Successful learning of a new language, for example, requires continuous feedback and improvement. However, it is the continuous self-optimization as the ultimate purpose of life, instead of merely serving as a means to an end that worries von Schirach.

She draws on many examples from Körperkult (body-cult), a slavish worship of the body that gradually replaces sensual pleasure with the purpose of discipling the body. Regular exercise and maintaining a normal weight are key factors for maintaining health but some individuals become so focused on tracking steps and sleep duration on their actigraphs, exercising or agonizing about their diets that the initial health-related goals become lose their relevance. They strive for a certain body image and resting heart rates and to reach these goals they indulge in self-discipline to maximize physical activity and curb appetite. Such individuals rarely solicit scientific information as to the actual health benefits of their exercise and food regimens and might be surprised to learn that more exercise and more diets do not necessarily lead to more health. The American Heart Association recommends roughly 30-45 minutes of physical activity daily to reduce high blood pressure and the risk of heart attacks and stroke. Even simple and straightforward walking is sufficient to meet these goals, there is no need for two-hour gym work-outs.

Why are we becoming so obsessed with self-optimization? Unfortunately, von Schirach’s analysis degenerates into a diffuse diatribe against so many different elements of contemporary culture. Capitalist ideology, a rise in narcissism and egotism, industrialization and the growing technocracy, consumerism, fear of death, greed, monetization of our lives and social media are among some of the putative culprits that she invokes. It is quite likely that many of these factors play some role in the emerging pervasiveness of the self-optimization culture – not only in Germany. However, it may be useful to analyze some of the root causes and distinguish them from facilitators. Capitalist ideology is very conducive to a self-optimization culture. Creating beauty and fitness targets as well as laying out timelines to achieve these targets is analogous to developing corporate goals, strategies and milestones. Furthermore, many corporations profit from our obsession with self-optimization. Companies routinely market weight regimens, diets, exercise programs, beauty products and many other goods or services that generate huge profits if millions of potential consumers buy into the importance of life-long self-optimization. They can set the parameters for self-optimization – ideal body images – and we just obey. According to the German philosopher Byung-Chul Han, such a diffusion of market logic and obedience to pre-ordained parameters and milestones into our day-to-day lives results in an achievement society which ultimately leads to mental fatigue and burnout. In the case of “working out”, it is telling that a supposedly leisure physical activity uses the expression “work”, perhaps reminding us that the mindset of work persists during the exercise period.

But why would we voluntarily accept these milestones and parameters set by others? One explanation that is not really addressed by von Schirach is that obsessive self-optimization with a focus on our body may represent a retreat from the world in which we feel disempowered. Those of us who belong to the 99% know that our voices are rarely heard or respected when it comes to most fundamental issues in society such as socioeconomic inequality, rising intolerance and other forms of discrimination or prejudice. When it comes to our bodies, we may have a sense of control and empowerment that we do not experience in our work or societal roles. Self-discipline of our body gives our life a purpose with tangible goals such as lose x pounds, exercise y hours, reduce your resting heart rate by z.

Self-optimization may be a form of Ersatzempowerment but it comes at a great cost. As we begin to retreat from more fundamental societal issues and instead focus on controlling our bodies, we also gradually begin to lose the ability to dissent and question the meaning of actions. Working-out and dieting are all about How, When and What – how do I lose weight, what are my goals, when am I going to achieve it. The most fundamental questions of our lives usually focus on the Why – but self-optimization obsesses so much about How, When and What that one rarely asks “Why am I doing this?” Yet it is the Why that gives our life meaning, and self-optimization perhaps illustrates how a purpose-driven life may lose its meaning. The fisherman prompted the tourist to think about the Why in Böll’s story and perhaps we should do the same to avoid the trap of an obsessive self-optimization culture.

The Affordable Care Act, also known as the “Patient Protection and Affordable Care Act”, “Obamacare” or the ACA, is a comprehensive healthcare reform law enacted in March 2010 which profoundly changed healthcare in the United States. This reform allowed millions of previously uninsured Americans to gain health insurance by establishing several new measures, including the expansion of the federal Medicaid health insurance coverage program, introducing the rule that patients with pre-existing illnesses could no longer be rejected or overcharged by health insurance companies, and by allowing dependents to remain on their parents’ health insurance plan until the age of 26. The widespread increase in health insurance coverage – especially for vulnerable Americans who were unemployed, underemployed or worked for employers that did not provide health insurance benefits – was also accompanied by new regulations targeting the healthcare system itself. Healthcare providers and hospitals were provided with financial incentives to introduce electronic medical records and healthcare quality metrics.

As someone who grew up in Germany where health insurance coverage is guaranteed for everyone, I assumed that over time, the vast majority of Americans would appreciate the benefits of universal coverage. One no longer has to fear financial bankruptcy as a consequence of a major illness and a government-back health insurance also provides for peace of mind when changing jobs. Instead of accepting employment primarily because it offers health benefits, one can instead choose a job based on the nature of the work. But I was surprised to see the profound antipathy towards this new law, especially among Americans who identified themselves as conservatives or Republicans, even if they were potential beneficiaries of the reform. Was the hatred of progressive-liberal views, the Democrats and President Obama who had passed the ACA so intense among Republicans that they were willing to relinquish the benefits of universal health coverage for the sake of their political ideology? Or were they simply not aware of the actual content of the law and opposed it simply for political reasons?

A recent study published by a team of researchers led by Sarah Gollust at the University of Minnesota may shed some light on this question. Gollust and her colleagues analyzed 1,569 local evening television news stories related to the ACA that were aired in the United States during the early months of when the health care reform was rolled out (between October 1, 2013, and April 19, 2014). They focused on analyzing local television news broadcasts because these continue to constitute the primary source of news for Americans, especially for those who are age 50 and higher. A Pew survey recently showed that 57% of all U.S. adults rely on television for their news, and among this group, local TV new (46%) is a more common source than cable news (31%) or network news (30%).

Gollust and colleagues found that 55% of the news stories either focused on the politics of the ACA such as political disagreements over its implementation (26.5%) or combined information regarding its politics with information on how it would affect healthcare insurance options (28.6%). Only 45% of the news stories focused exclusively on the healthcare insurance options provided by the law. The politics-focused news stories were also more likely to refer to the law as “Obamacare” whereas healthcare insurance focused news segments used the official name “Affordable Care Act” or “ACA”. Surprisingly, the expansion of Medicaid, which was one of the cornerstones of the ACA because it would increase the potential access to health insurance for millions of Americans, was often ignored. Only 7.4% of news stories mentioned Medicaid at all, and only 5% had a Medicaid focus.

What were the sources of information used for the news stories? President Obama was cited in nearly 40% of the stories, whereas other sources included White House staff or other federal executive agencies (28.7%), Republican (22.3%) or Democratic (15.9%) politicians and officials. Researchers, academics or members of think tanks and foundations were cited in only 3.9% of the news stories about the ACA even though they could have provided important scholarly insights about the ACA and its consequences for individual healthcare as well as the healthcare system in general.

The study by Gollust and colleagues has its limitations. It did not analyze TV network news, cable news, or online news outlets which have significantly gained in importance as news sources during the past decade. The researchers also did not analyze news stories aired after April 2014 which may have been a better reflection of initial experiences of previously uninsured individuals who signed up for health insurance through the mechanisms provided by the ACA. Despite these limitations, the study suggests that one major reason for the strong opposition among Republicans against the ACA may have been the fact that it was often framed in a political context and understated the profound effects that the ACA had on access to healthcare and the reform of the healthcare system itself.

During the 2016 election campaign, many Republican politicians used the idea of “repealing” the ACA to energize their voters, without necessarily clarifying what exactly they wanted to repeal. Should all the aspects of the ACA – from the Medicaid expansion to the new healthcare quality metrics in hospitals –be repealed? If voters relied on the local television news to learn about the ACA, and if this coverage – as is suggested by Gollust’s study – viewed the ACA predominantly as a political entity, then it is not surprising that voters failed to demand nuanced views from politicians who vowed to repeal the law. The research also highlights the important role that television reporting plays in framing the debate about healthcare reform. By emphasizing the actual content of the healthcare reform and its medical implications and by using more scholars instead of politicians as information sources, these media outlets could educate the public about the law.

There are many legitimate debates about the pros and cons of the healthcare reform that are not rooted in politics. For example, electronic medical records allow healthcare providers to easily monitor the results of laboratory tests and avoid wasting patient’s time and money on unnecessary tests that may have been ordered by another provider. However, physicians who are continuously staring at their screens to scroll through test results may not be able to form the interpersonal bond that is critical for a patient-doctor relationship. One could consider modifying the requirements and developing better record-keeping measures to ensure a balance between adequate documentation and sufficient face-to-face doctor-patient time. The ACA’s desire to track quality of healthcare delivery and penalize hospitals or providers who deliver suboptimal care could significantly improve adherence to guidelines based on sound science. On the other hand, one cannot demand robot-like adherence to guidelines, especially when treating severely ill, complex patients who require highly individualized care. These content-driven discussions are more productive than wholesale political endorsements or rejections of the healthcare reform.

Healthcare will always be a political issue but all of us – engaged citizens, patients, healthcare providers or journalists – need to do our part to ensure that this debates about this issue which directly impacts millions of lives are primarily driven by objective information and not by political ideologies.